b) You may use the label "Additonal info" to supply any other information relating to your professional status.

c) Please select the appropriate box, "YES/NO" as applicable.

d) This application will be considered incomplete unless all questions are answered. Completing the form does not bind the applicant or Medical Assocation of Jamaica Insurance Fund (MAJIF) to complete the insurance.

.

Basic Information

Speciality:

check if you have sub specialities

Sub speciality:

Application Type

New:
Reinstatement:

First Name:

Middle Name:

Last Name:

Address of Practice:

Mailing Address:

Date of Birth:

/
MM
/
DDYYYY

Email Address:

Sex:

Male:
Female:

Telephone

(Work):

(Home):

(Cell):

Practice Information

Year Of Graduation:

YYYY

Number of Years Practice:

Name and Address of Medical School:

Name:

Address:

Internship Information

Internship(1):

Date:
/
MM
/
DDYYYY

Place :

Internship(2):

Date:
/
MM
/
DDYYYY

Place :

Internship(3):

Date:
/
MM
/
DDYYYY

Place :

Post Internship Information

Internship(1):

Date:
/
MM
/
DDYYYY

Place :

Duty :

Internship(2):

Date:
/
MM
/
DDYYYY

Place :

Duty :

Internship(3):

Date:
/
MM
/
DDYYYY

Place :

Duty :

Registration Information

Are you registered with the Medical Council of Jamaica ?

Yes:
No:

Registration Number:

Expiry Date:

/
MM
/
DDYYYYY

Sub Speciality:

Primary Hospital Affiliation:

Would you need to do any of the following:

Practice outside of Jamaica ?

Yes:
No:

If yes please specify:

Have coverage outside Jamaica ?

Yes:
No:

If yes please specify:

Do you do any of the following:

Laser surgery ?

Yes:
No:

If yes please specify:

Laproscopic surgery ?

Yes:
No:

If yes please specify:

Liposuction ?

Yes:
No:

If yes please specify:

Transplant surgery ?

Yes:
No:

if yes please specify:

Order or perform Blood Transfusions ?

Yes:
No:

If yes please specify:

Any form of experimental surgery ?

Yes:
No:

If yes please specify:

New drug trials ?

Yes:
No:

if yes please specify:

Do you now carry Professional Indemnity Coverage ?

Yes:
No:

If yes please specify:

Expiry Date:

/
MM
/
DDYYYYY

Policy #:

Have you ever been declined Professional Indemnity Coverage ?

Yes:
No:

If yes state reason:

Have you ever had your Professional Indemnity policy cancelled, refused at
Renewal or had special terms imposed ?

Yes:
No:

If yes state reason:

Have you ever had a medical negligence suit against you ?

Yes:
No:

If yes give details:

Do you have any medical negligence suits pending against you ?

Yes:
No:

If yes give details:

Are you aware of any circumstances that may result in medical negligence claim being made against you ?

Yes:
No:

If yes please state:

Do you supervise Ancillary Technical Personnel ?

Yes:
No:

If yes give details:

Additional

Rate Calculation

Speciality

Sub Speciality:

Group

Please indicate amount of coverage required:

Basic Premium

$

Do you practice overseas?
if yes please select the country:

Do practice any of the following :

Proposed commencement of Policy

Payment

Total Premium

$

First Installment

$

Addtional Installments

$

Clear Values

I HEREBY DECLARE: that the above statement and particulars are true and that i have not suppressed or misstated any material facts and i agree that this Proposal Form and any supplementary information sheet(s) attached hereto shall be the basis of the contract with the Medical Association of Jamaica Insurance Fund(MAJIF).